Addictions From an Attachment Perspective: Do Broken Bonds and Early Trauma Lead to Addictive Behaviours?

This outstanding book is an important collection of papers from the 2013 John Bowlby Memorial Conference by accomplished clinicians from different modalities who share their experience of working with people with different kinds of addiction. The papers bring together an in-depth understanding that addictions are a response to, and hold the pain of, broken attachments and are best treated within healthy interpersonal relationships. For a long time the person with an addiction has been seen as the problem with society being able to live in denial of the causes. These papers open up innovative and effective ways of working with people troubled by addiction from an attachment-informed perspective.Contributors: Cara Crossan, Richard Gill, Lynn Greenwood, Bob Johnson, Liz Karter, Edward Khantzian, Arlene Vetere, Kate White, Jason Wright

Lecture was given by Colin Murray-Parkes on the theme of mourning and loss. That was a fitting recognition of Bowlby’s great contribution to the understanding of human grief and sadness, while his clinical observations of separation and loss laid down the foundations of attachment theory.

This year’s lecturer is Edward Khantzian a pioneer of how addiction has come to be understood as a process of self-medication which has fundamentally changed the way it is treated. He is a clinical professor of psychiatry of Harvard Medical School and one of the founders of the American Academy of Addiction Psychiatry. His view is that people who are addicted are “in need of being understood not so much as pleasure seekers or self-destructive characters, but more as individuals who are in pain and seek and need contact and comfort”. (Khantzian,

This year marks twenty years since the first John Bowlby Memorial Lecture was given by Colin Murray-Parkes on the theme of mourning and loss. That was a fitting recognition of Bowlby's great contribution to the understanding of human grief and sadness, while his clinical observations of separation and loss laid down the foundations of attachment theory.

This year's lecturer is Edward Khantzian a pioneer of how addiction has come to be understood as a process of self-medication which has fundamentally changed the way it is treated. He is a clinical professor of psychiatry of Harvard Medical School and one of the founders of the American Academy of Addiction Psychiatry. His view is that people who are addicted are “in need of being understood not so much as pleasure seekers or self-destructive characters, but more as individuals who are in pain and seek and need contact and comfort”. (Khantzian, 2014, p. 33 this volume) The roots of addiction, in his view, lie in early attachment and relational trauma.

iven the scope of this essay, the breadth of it’s subject and its origins as the opening paper of a conference, I will take a quite personal view of the literature and the field. I start with a quotation which is a reflection of the author Zeyl on the work of Plato‘s

Timaeus.

The well being of the soul in particular is emphasized: it is through realigning the motions of our souls with those of the universe at large that we achieve our goal of living virtuously and happily.

(Zeyl, 2013, p. 1)

My contribution will fall into three sections: a description of my work with users, a few vignettes, and a discussion of context. When thinking about how we approach working with someone struggling with addiction, I have found it useful to start from what might be seen as the typical path an addict will follow through their using career.1 We can use that progression as a structure for thinking, both in terms of appropriate intervention as well as in terms of meaning (much like how one might think about what point an individual is at in their life path when we meet them: youth, middle age or old age, pre or post children, in or out of a relationship). So my approach to the practical work undertaken

Given the scope of this essay, the breadth of it's subject and its origins as the opening paper of a conference, I will take a quite personal view of the literature and the field. I start with a quotation which is a reflection of the author Zeyl on the work of Plato's Timaeus.

The well being of the soul in particular is emphasized: it is through realigning the motions of our souls with those of the universe at large that we achieve our goal of living virtuously and happily. (Zeyl, 2013, p. 1)

My contribution will fall into three sections: a description of my work with users, a few vignettes, and a discussion of context. When thinking about how we approach working with someone struggling with addiction, I have found it useful to start from what might be seen as the typical path an addict will follow through their using career.1 We can use that progression as a structure for thinking, both in terms of appropriate intervention as well as in terms of meaning (much like how one might think about what point an individual is at in their life path when we meet them: youth, middle age or old age, pre or post children, in or out of a relationship). So my approach to the practical work undertaken with addicts, as shown in the vignettes I use as examples, follows this form as does my thinking about the context for our work.

The Self-Medication Hypothesis and attachment theory: pathways for understanding and ameliorating addictive suffering

The twentieth John Bowlby Memorial Lecture

Edward. J. Khantzian

Introduction

Our pejorative and unempathic attitude towards individuals labelled as having “Substance Use Disorders” (SUDs) in part derives from early psychoanalytic drive theory. Dual instinct theory suggested that addictive behaviour is driven by pleasure seeking or self-destructive motives, so much so that in the latter instance Menninger (1935) stated that addiction was suicide on an installment plan. What a misunderstanding. Our patients with “addictive disorders” are in need of being understood not so much as pleasure seekers or self-destructive characters, but more as individuals who are in pain and seek and need contact and comfort.

The Self-Medication Hypothesis (SMH) derives from persistent clinical observation and inquiry about how individuals who depend on addictive substances do so because they have had the powerful discovery that what they suffer with is relieved temporarily by addictive substances.

Our pejorative and unempathic attitude towards individuals labelled as having “Substance Use Disorders” (SUDs) in part derives from early psychoanalytic drive theory. Dual instinct theory suggested that addictive behaviour is driven by pleasure seeking or self-destructive motives, so much so that in the latter instance Menninger (1935) stated that addiction was suicide on an installment plan. What a misunderstanding. Our patients with “addictive disorders” are in need of being understood not so much as pleasure seekers or self-destructive characters, but more as individuals who are in pain and seek and need contact and comfort. The Self-Medication Hypothesis (SMH) derives from persistent clinical observation and inquiry about how individuals who depend on addictive substances do so because they have had the powerful discovery that what they suffer with is relieved temporarily by addictive substances. This is so whether it is a vague sense of dysphoria because feelings are confusing or elusive, or because affects are overwhelming and unbearable. Depending on the substance used, the psychoactive actions of the drugs of abuse provide short term surcease for a wide range of painful and confusing feeling states.

Alcohol misuse, attachment dilemmas, and triangles of interaction: a systemic approach to practice

Arlene Vetere

For not only young children, it is now clear, but human beings of all ages are found to be at their happiest and to be able to deploy their talents to best advantage when they are confident that, standing behind them are one or more trusted persons who will come to their aid should difficulties arise. The person trusted provides a secure base from which his (or her) companion can operate.

—Bowlby, 1973, p. 407

Attachment theory: implications for systemic therapy

Attachment theory has many important and helpful implications for therapeutic practice with individuals, couples, and families where alcohol misuse is the focus of concern, and not least, because attachment theory conceptualises heavy drinking as a problem of affect regulation. Attachments are considered to be representational, about caregiving, comfort, and affection, and in adult relationships, about sexuality.

For not only young children, it is now clear, but human beings of all ages are found to be at their happiest and to be able to deploy their talents to best advantage when they are confident that, standing behind them are one or more trusted persons who will come to their aid should difficulties arise. The person trusted provides a secure base from which his (or her) companion can operate.

—Bowlby, 1973, p. 407

Attachment theory: implications for systemic therapy

Attachment theory has many important and helpful implications for therapeutic practice with individuals, couples, and families where alcohol misuse is the focus of concern, and not least, because attachment theory conceptualises heavy drinking as a problem of affect regulation. Attachments are considered to be representational, about caregiving, comfort, and affection, and in adult relationships, about sexuality. Attachment theory does not pathologise dependency in our relationships with key attachment figures, rather seeing autonomy and effective dependency as different sides of the same attachment coin. In this chapter, I shall explore the weave of attachment theory with systemic thinking and practice to consider how a person might come to rely on alcohol before people, and to trust alcohol to “look after them” more reliably than any person could or might (Dallos & Vetere, 2009).

I first worked with Debbie when she was admitted to the in-patient eating-disorders unit of a private hospital for an eight-week treatment programme to address her entrenched patterns of food restriction, bingeing and vomiting. My weekly session of psychotherapy was part of a broader programme of psychological and practical groups, regular time with a key-worker and occasional appointments with a dietician; pretty standard in such an environment.

Debbie was thirty-one, married to Steve for five years and employed at the senior level of middle management by a blue-chip company. She was diagnosed with bulimia nervosa, symptoms of which include frequent episodes of binge eating and behaviours designed to compensate for this (laxatives, self induced vomiting, diuretics, over-exercise) plus a self-image that is defined by weight and body shape.

Debbie found her stay on the unit very difficult. The other patients were all severely underweight and on weight-gain diets (at least 0.6 kg per week) with the aim of reaching a BMI (Body Mass Index) of at least twenty.

first worked with Debbie when she was admitted to the in-patient eating-disorders unit of a private hospital for an eight-week treatment programme to address her entrenched patterns of food restriction, bingeing and vomiting. My weekly session of psychotherapy was part of a broader programme of psychological and practical groups, regular time with a key-worker and occasional appointments with a dietician; pretty standard in such an environment.

Debbie was thirty-one, married to Steve for five years and employed at the senior level of middle management by a blue-chip company. She was diagnosed with bulimia nervosa, symptoms of which include frequent episodes of binge eating and behaviours designed to compensate for this (laxatives, self induced vomiting, diuretics, over-exercise) plus a self-image that is defined by weight and body shape.

Debbie found her stay on the unit very difficult. The other patients were all severely underweight and on weight-gain diets (at least 0.6 kg per week) with the aim of reaching a BMI (Body Mass Index) of at least twenty.

first worked in a unit for drug addicts in New York state as a senior psychiatrist in 1965. I was struck then by the behaviour patterns that are so prevalent in this group of clients. In the forty-eight years since, I have been deeply impressed by two things, first, that addiction takes an infinite number of forms limited only by the human imagination. Thus we have addictions to any human activity you care to name; sex, hobbies, money, work, violence, and stalking, together with the more conventional ones of gambling, alcohol, nicotine, legal, and illegal drugs.

Second, every addict I have met, especially those in Parkhurst Prison, has made what appears to be a choice to bury themselves in the addiction, to persist in what everyone else can see as self-destructive behaviour, driven there by severe and heavily obscured emotional pain. If the addict once desists, they are terrified that the emotional pain that they fear so much will overwhelm them so they continue their addiction, whatever it might be, as if their life depended on it, which, as they see it, it does. The roots of this “long term suicide” are to be found in their earliest mal-attachments, just as Bowlby saw with such clarity in his concept of how insecure attachment patterns develop from early relational misattunement and trauma. The term mal-attachment I use

I first worked in a unit for drug addicts in New York state as a senior psychiatrist in 1965. I was struck then by the behaviour patterns that are so prevalent in this group of clients. In the forty-eight years since, I have been deeply impressed by two things, first, that addiction takes an infinite number of forms limited only by the human imagination. Thus we have addictions to any human activity you care to name; sex, hobbies, money, work, violence, and stalking, together with the more conventional ones of gambling, alcohol, nicotine, legal, and illegal drugs.

Second, every addict I have met, especially those in Parkhurst Prison, has made what appears to be a choice to bury themselves in the addiction, to persist in what everyone else can see as self-destructive behaviour, driven there by severe and heavily obscured emotional pain. If the addict once desists, they are terrified that the emotional pain that they fear so much will overwhelm them so they continue their addiction, whatever it might be, as if their life depended on it, which, as they see it, it does. The roots of this “long term suicide” are to be found in their earliest mal-attachments, just as Bowlby saw with such clarity in his concept of how insecure attachment patterns develop from early relational misattunement and trauma. The term mal-attachment I use as shorthand for where the original attachment bond is less than sound. The remedy, across the board, is to prove to the person's satisfaction that adult interdependence is vastly superior to any residues of infantile dependence, not always easy to secure, but infinitely fruitful when it is.

When I first saw the title of the conference, “Do broken bonds and early trauma lead to addictive behaviours?”, I thought yes, of course they do, end of story. But does just the knowledge of broken bonds and early trauma help a person to stop an addiction? I thought no, not in my experience, only indirectly, there is too much history in the way. I hope I can go some way in this chapter to explain this, describe where a chemically dependent person is at when thinking of stopping and what is needed for recovery.

I begin by quoting from Flores (2004), to outline some of the underlying basis of my understanding of the links between our attachment needs and addiction and then expand on this with my experience of working with people with various forms of addiction.

John Bowlby saw the need for healthy relationships that provide mutual affect regulation as an integral part of human behaviour from the “cradle to the grave”. Kohut agreed, and said that we never outgrow our need for self objects, and that therapy is only complete when the person can form healthy attachments outside the therapeutic milieu. Another very important aspect of attachment theory and self psychology is their compatibility with the fellowship of AA (Alcoholics Anonymous). Kohut viewed the narcissistic disorder as the expression of a reaction to injury of the self, and regarded the experience of the bond between the self and the self object to be crucial for psychological health and growth, Kohut is implying that there is an inverse relationship between individual's early experience of the positive self object responsiveness and their propensity to turn to alcohol, drugs and other sources of gratification as substitutes for these missing or damaging relationships.

hen I first saw the title of the conference, “Do broken bonds and early trauma lead to addictive behaviours?”, I thought yes, of course they do, end of story. But does just the knowledge of broken bonds and early trauma help a person to stop an addiction? I thought no, not in my experience, only indirectly, there is too much history in the way. I hope I can go some way in this chapter to explain this, describe where a chemically dependent person is at when thinking of stopping and what is needed for recovery.

I begin by quoting from Flores (2004), to outline some of the underlying basis of my understanding of the links between our attachment needs and addiction and then expand on this with my experience of working with people with various forms of addiction.

John Bowlby saw the need for healthy relationships that provide mutual affect regulation as an integral part of human behaviour from the “cradle to the grave”. Kohut agreed, and said that we never outgrow our need for self objects, and that therapy is only complete when the person can form healthy attachments outside the therapeutic milieu. Another very important aspect of attachment theory and self psychology is their compatibility with the fellowship of AA

Since the 1980s, sexually addictive behaviour has received an increased amount of attention with some arguing that this disorder should either be classified as sexual compulsion, hypersexuality or problematic sexual behaviour (Giugliano, 2006; Gold & Hefner, 1998; Goodman, 1998). Amongst clinicians, there appears to be a lack of consensus when writing about this topic. There has been a great deal of controversy regarding how we define sexual addiction with the definition differing between articles. Authors such as Kalichman and Rompa (2001), and Quadland (1985) have changed the definition several times throughout their papers. The lack of research supporting any one particular theory or concept has helped explain why some clinicians have used the terms interchangeably (Giugliano, 2006; Gold & Hefner, 1998; Hook, Hook & Hines, 2008; Lloyd, Raymond, Miner & Coleman, 2007).

The internet has changed the face of sexual addiction and how clients are presenting for treatment.

Since the 1980s, sexually addictive behaviour has received an increased amount of attention with some arguing that this disorder should either be classified as sexual compulsion, hypersexuality or problematic sexual behaviour (Giugliano, 2006; Gold & Hefner, 1998; Goodman,

1998). Amongst clinicians, there appears to be a lack of consensus when writing about this topic. There has been a great deal of controversy regarding how we define sexual addiction with the definition differing between articles. Authors such as Kalichman and Rompa (2001), and

Quadland (1985) have changed the definition several times throughout their papers. The lack of research supporting any one particular theory or concept has helped explain why some clinicians have used the terms interchangeably (Giugliano, 2006; Gold & Hefner, 1998; Hook, Hook &

er statement, for that is what it was, was made solemnly with a depth of meaning and feeling by a woman with a long-term history of cross addiction, beginning with alcohol, moving on through crack cocaine, moving onto addiction to slot machine playing. To this woman—as to many men and women—by far the hardest addiction to overcome is that of gambling addiction. For the woman I speak of her pattern of addiction lasting over twenty-five years becoming ultimately so destructive it resulted in five of her eleven children being taken into care.

So, if we are honest with ourselves, what do we see when initially we visualise this woman Carla? Perhaps we see a chaotic and irresponsible woman, who certainly is old enough to know better? What

This group is not like Gamblers Anonymous, this group is scarier…it's like family.

—Carla, aged forty-nine, a slot machine player

Her statement, for that is what it was, was made solemnly with a depth of meaning and feeling by a woman with a long-term history of cross addiction, beginning with alcohol, moving on through crack cocaine, moving onto addiction to slot machine playing. To this woman—as to many men and women—by far the hardest addiction to overcome is that of gambling addiction. For the woman I speak of her pattern of addiction lasting over twenty-five years becoming ultimately so destructive it resulted in five of her eleven children being taken into care.

So, if we are honest with ourselves, what do we see when initially we visualise this woman Carla? Perhaps we see a chaotic and irresponsible woman, who certainly is old enough to know better? What I came to see as both Carla's one to one and women's group therapist was a frightened child—around eleven years’ old—who just happened to be in the body of an adult woman. Carla never knew her father and was abandoned by her mother at the age of eleven when she left her to be cared for by her grandmother, in her home country of Jamaica, promising she would return. She never did. Her uncle at times would be put in charge of taking care of her whilst her grandmother worked. He would take her to the cellar and sexually abuse her. Everything Carla had done from that time on made sense if seen through the perspective of the mind of that desperately lonely and scared little girl that she was. She imagined having eleven children would guarantee that she would never experience the insufferable pain and fear of loneliness again, but without the associated risks of adult interaction and relationship. The crack cocaine was used as self-medication, helping to transcend the impossibly difficult world that she did not know she was creating by having such a large family. It blocked out any memories or flashbacks of her traumatic experience of childhood sexual abuse. Similarly compulsively pushing money into a slot machine, staring at a computer screen whilst she gambled was a desperate attempt to numb her pain.